Virtual Ability have another great event planned for late next week – here’s the full press release:

Virtual World Conference Supports Quality of Life in Mental Health

Virtual Ability, Inc. announces the third annual Mental Health Symposium to be held Saturday, April 26th, 7:00 am PDT/SLT to 5:00 pm PDT/SLT in Second Life®. The theme of this year’s conference is “Quality of Life.”

The World Health Organization defines quality of life as an individual’s “perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, standards and concerns.”

Quality of life is important to us all, but may be more difficult to attain for those with mental health issues. Overall quality of life is affected by psychological state, physical health, level of independence, social relationships, personal values and beliefs, and the relationship of all of these to the person’s environment.

Symposium presentations include (in alphabetical order):
• Hillary Bogner, MD, University of Pennsylvania, Perelman School of Medicine, will offer insights from her research on depression among older adults.
• Colleen Crary, Executive Director of Fearless Nation, Inc., will share lessons from adversity for creating a vibrant life.
• Dick Dillon, CEO of Innovaision, LLC, shares surprising information about why some recovering addicts become “weller than well.”
• Teresa Goddard, Senior Consultant with the Job Accommodation Network, will inform us about attaining employment equality through accommodation and self-advocacy.
• Dr. Christine Karper and Michelle Stone, members of the American Counseling Association’s Cyber Task Force, will talk about the role of counseling and virtual service delivery.
• Dr. Jacquelyn Ford Morie, University of Southern California, will describe the use of virtual worlds as healing spaces for veterans.
• Dr. Nicolas Rüsch, of the University of Ulm, Baden-Wurttemberg, Germany, will explain the results of his research on well-being among persons at risk of psychosis, focusing particularly on shame and stigma.

Alice Krueger, president of Virtual Ability, Inc., stated: “I am pleased to see an increasing focus on quality of life in mental health care in recent years, since many persons with mental health diagnoses struggle with these issues. The Symposium’s international presenters are acknowledged experts in their fields. I will be interested to hear what they have to say on these important topics. Please join us on April 26 to learn more from a variety of exciting speakers!”

About Virtual Ability, Inc.
Virtual Ability, Inc. is a 501(c)(3) non-profit corporation based in Denver, Colorado, dedicated to enabling people with a wide range of disabilities by providing a supporting environment for them to enter and thrive in on-line virtual worlds like Second Life®.

For more information on Virtual Ability, Inc., including the benefits of virtual worlds for people with disabilities, please see www.VirtualAbility.org.

John Wilson has done an interesting interview with Edina Renfro-Michel from Montclair State University. The topic is the education of counsellors, and the outcome has been improved learning outcomes from students who took part in the Second Life than those who didn’t.

As Edina mentioned in the interview, the virtual worlds aspect improved overall knowledge i.e. those student integrated their wider learning from textbooks, podcasts etc as well. It’s a recurring and somewhat unsurprising theme: the 3D learning experience is improving outcomes.

It’s coming up to a year since we interviewed DeeAnna Nagel and Kate Anthony and discussed counselling in online environments broadly and in virtual environments more specifically. Over that time, the Online Therapy Institute has continued to grow. One example of this is the announcement of a five-hour course on online supervision.

Anyone who works in a counselling role will understand the importance of supervision as both a development and protective mechanism for a practitioner, let alone one working in an online environment. Additionally, a key plank of more widespread acceptance of online therapy is formalised governance mechanisms that provide peace of mind in regards to quality. Small steps like the ones taken here are helping to achieve just that.

The wider challenge is establishing e-health standards that ensure confidentiality, the ability to confirm practitioner credentials and good service navigation for face-to-face intervention when required. That sort of integration is potentially years off, but in the meantime counselling professionals are doing a great job of filling in the gaps.

If you’re involved in counselling in a virtual world environment, I’d love to hear from you to find out more about your work.

Update: an interview with the Online Therapy Institute in Second Life is now available:

DeeAnna Nagel and Kate Anthony are psychotherapists and founders of the Online Therapy Institute. The pair have only recently expanded their work to Second Life, but they have extensive experience in working with people therapeutically online. The pair now have a presence on Jokaydia in Second Life. I caught up with them to talk online counselling / therapy.

Lowell: Can you give a brief outline of your professional experience /qualifications pre-Second Life / online therapy?

DeeAnna: I have a Master of Education in Rehabilitation Counseling and a Bachelor of Science in Mental Health and Human Services. I have worked in the mental health field for nearly 20 years. About 10 years ago I discovered the power of the Internet and began providing online chat and email through a couple of e-clinics. Over the years I have always maintained a part-time practice online and have integrated technology in work settings working with interns, employees and clinical supervisees. I have been training therapists since 2001 about the ethical issues pertaining to technology and mental health. Now 100% of my work life is devoted to either providing online therapy or teaching others about online therapy.

Kate Anthony: I have a Master of Science in Therapeutic Counselling and a Bachelor of Science in Psychology, and am halfway through a PhD on the topic of Technology and Mental Health. At around the same time as I discovered how powerful relationships over the Internet can be and based my MSc thesis on that. From that, I co-authored the British Association for Counselling and Psychotherapy (BACP) Guidelines for Online work (including Supervision) through its 3 editions. I have trained mental health professionals to work online since 2002, have published widely including textbooks, and was recently made a Fellow of BACP for my work and DA and I are both past-Presidents of the International Society for Mental Health Online (ISMHO).

Lowell Cremorne: What was the event that led to you realising the potential of virtual worlds for counselling interventions

DeeAnna Nagel: There was no single event for me; just a realisation that virtual world settings offer another level of sensory experience that could enhance the therapeutic process.

Kate Anthony: I realised this in 2001 after speaking at a conference about Telephone Helplines. The Keynote speaker was head of BTExact Technologies, and he referred to the future of virtual worlds, and avatars specifically, being part of the future of health care. Most of the audience was laughing at the concept -– I wasn’t. I went on to work with him and his team to explore the concept and write a white paper on the topic (Anthony, K. and Lawson, M (2002). The Use of Innovative Avatar and Virtual Environment Technology for Counselling and Psychotherapy. Available online at www.kateanthony.co.uk/research).

DeeAnna Nagel: The potential for therapeutic intervention in virtual world settings is already available – but not necessarily cost-effective for the private practitioner. Second Life is not encrypted and while we could offer therapy using secure methods such as a Sky Box, we have chosen not to. Proprietary software is being developed by companies and institutions for use in SL and other virtual worlds, and at some point private practitioners will be able to provide secure and encrypted services. Until that happens, we can, as you say, utilise our SL office as a way to meet people who want to provide an avatar representation and for other educational and consultancy opportunities.

Lowell Cremorne: What do you think needs to occur for people to be able to trust in-world therapy?

DeeAnna Nagel: Security including encryption is paramount. In addition, virtual world platforms need to be less cumbersome and be able to run on different platforms without the constant risk of technological breakdowns.

Lowell Cremorne: A common component of media coverage of virtual worlds is addiction – for the small percentage of people who may have a definable addiction, can the cause also play a role in the treatment? What I’m getting at here is whether in-world therapy for those addicted to virtual world interaction is a sensible treatment option or a damaging option.

DeeAnna Nagel: This should be taken on a case-by-case basis- I do offer online text-based therapy via chat and email to people who identify with Internet addiction. I think working with addicts inworld allows the client to experience a healthy relationship online and offers a way to model use of technology in appropriate ways. Technology is such a part of our social and vocational fabric now that people need to be able to integrate back to using technology but in healthy ways with appropriate boundaries. The work becomes about establishing and maintaining healthy relationships just as we have done with face-to-face clients for years.

Lowell Cremorne: Rapport-building is key for successful therapy – how best is that done online?

DeeAnna Nagel: Consideration should be given to the disinhibition effect. Online, people are less inhibited and likely to disclose information due to the person’s sense of anonymity. When working therapeutically, on the surface, this can be a plus in establishing rather quick rapport, but therapists also have a responsibility to prepare clients about disclosing personal information too quickly and then helping the client modulate the emotional intensity throughout the process.

Kate Anthony: The concept of “presence” is also important here – where is the client and where are you during the process? Most of my trainees agree post-training that the therapeutic work takes place somewhere between the two pieces of hardware (including mobile hardware) in Cyberspace. The mutual journey – and the rapport that goes with it – seems to take place in a nebulous arena, but actually the understanding by both client and counsellor as to how it exists for them facilitates the rapport.

Lowell Cremorne: How much real-world identification do you believe needs to occur prior to therapy commencing?

Kate Anthony: I think it essential for the client to be able to verify identity of the therapist, but this could be done via a third party – such as a professional organisation. Opinion varies widely from a client-identification point of view. Purists prefer to work with whatever the client is offering, subject to some legal identity checks in some places such as the client possibly being under age. The argument there is that the psyche that the client presents, via avatar or text, is a valid psyche to work with. Other practitioners prefer to make several checks as to how the client exists offline (we feel the phrase “real-world” is outdated, incidentally, so prefer to refer to online and offline). Personally, I feel that with a robust intake form and assessment procedure, further identification may simply get in the way of the therapeutic work which often depends on uniquely online societal norms (such as disinhibition and the perceived anonymity).

Kate Anthony (L) and DeeAnna Nagel (R)

Lowell Cremorne: Is confirming real world gender / age / cultural identity important for good therapeutic outcomes online?

DeeAnna Nagel: Yes- as with face-to-face, the person’s identification is important to determine if the work between therapist and client is a good fit. Cultural differences should be taken on a case-by-case basis.

Kate Anthony: Yes, particularly with regard to age and informed consent.

Lowell Cremorne: What issues / mental health states would you feel uncomfortable dealing with online?

DeeAnna Nagel: For the most part, I am comfortable working with people online that have issues I am comfortable working with face-to-face. As long as I feel competent about the clinical issues and have the proper training, most mental health interventions can occur online. For me, it is difficult to work with someone who is obviously intoxicated or obviously decompensating and showing signs of delusional and irrational behavior- but this is whether the client is face-to-face or online. Certainly, when working via distance, the client’s geographical resources should be determined should crisis intervention become necessary.

Kate Anthony: And that exact point is how I train upcoming online mental health professionals– that with the Internet it is simple to explore a clients alternative crisis interventions based on their geographical location. Other concerns are working with people who are in a relationship that involves domestic violence. Safety issues for the victim come into play if he or she is using a computer that the perpetrator has access to and may be monitoring with a keystroke program.

Lowell Cremorne: Whether it be in a virtual world or via more traditional online methods, do you find you’re less likely to run into personal boundary issues, or is it just as much a challenge?

DeeAnna Nagel: For me, the boundaries are not blurred. I have always maintained boundaries in person and online but with the advent of social networking, I am consulting with more and more professionals who are struggling with this issue. What to do if a client friends their therapist on Facebook for instance and many times the dilemmas are ethical in nature- with regard to either confidentiality or dual relationships.

Lowell Cremorne: Are you aware of any formalised professional associations for online therapists to communicate and if not, how do you see the momentum developing so that this occurs?

Kate Anthony: There is the International Society for Mental Health Online (ISMHO) as mentioned, and more recently ACTO-UK (Association for Counsellors and Therapists Online – UK) – an organisation for UK based online therapists. The latter is holding it’s first conference (online and offline simultaneously) in April. Our fear is that many small organisations will crop up here and there with narrow ideas – what the Online Therapy Institute strives for is a global agreement as to how each of these associations can work together to disseminate knowledge and stimulate growth of the field to the greater good of online work, whether in virtual worlds or via other modalities.

Lowell Cremorne: What are your plans over the coming year for your Second Life work? Have you considered other worlds?

DeeAnna Nagel: We explore other worlds as they appear, and not always necessarily in an obvious way. For example, the Online Therapy Institute has a strong interest in the prevention and treatment of Cyberbullying, and a virtual world such as Club Penguin, for example, could be instrumental in that aim. Plans for the coming year is to explore those platforms that meet the Institute’s requirements for safe and secure client-therapist interaction, and continue to develop training for conducting therapy in virtual worlds.

I spend hours with my computer. It is my favorite tool. I spend time in and out of virtual worlds; I spend time on and off the Internet, surfing with my browser. I communicate, I work, I play. From the sheer amount of time spent with my machine during the day, according to some measures, it would be correct to say that I am addicted to the behaviour of using my computer. I do not, however, consider this to be an addiction.

Several people within my experience also spend a great deal of time with their computers. Interestingly, the particular people I am thinking of were also at one time thought to be drug addicts. Each of these people suffers from either a physical pain disorder, or from a chemical mental disorder. The drugs they take assist their functioning, above and beyond the side effects they cause. I do not consider any of these people to be addicts, either, with regards to drug use or computer use.

Why is this not addiction?

The most important signs of addiction, and indeed the ones that cry out for treatment, are loss of control regarding the addiction and destructive behaviors of and surrounding the addiction. Neither I nor my friends exhibit these signs in our computer usage nor drug usage; therefore, this behavior is not an addiction, by definition.

Why does it look like addiction?

One of the primary signs attributed to addictions of computer usage is time spent engaging in the behavior. This sign may help with the diagnosis of an addiction, but alone cannot be used to make the diagnosis.

Consider how many hours a day the average person spends at work. Perhaps eight hours all up, divided into an hour for lunch, a couple of hours for meetings and other communications, and the rest for the actual work they do. Then consider that person gets home (two hours for travel), eats (two hours for eating at home), and watches TV or reads (four hours). This accounts for sixteen hours of the day, roughly.

Imagine, then, if all of this could be accomplished from their computer at home. Suddenly, rather than seeing a person spending sixteen hours a day in mindless clicking, there is someone working, communicating, gathering news and information and finding entertainment using the same tool.

Another sign often taken alone and out of context is a lack of face-to-face communication on behalf of a person who uses computers.

There are many different scenarios in which face-to-face communication is not applicable, but for example, consider a person with a physical disability in which face-to-face communication is difficult to achieve. For someone with limited mobility or large amounts of pain, getting out of the house may range from impractical to impossible. Consider sufferers of social anxieties, or autistic folk, who are barely able to communicate face-to-face, but whom are liberated by the digital space.

Is quality of life being gained or lost?

Where there is a gain in quality of life which exceeds the downsides to the behavior, there is unlikely to be an addictive problem. With drugs for pain relief, it has been found that it’s very rare for folks who require the drug for pain relief to exhibit loss of control or destructive behaviors concerning the drug, even though they have a physical dependence on it. There may be withdrawal symptoms and side effects, but overall the quality of life increase for these folks. Being able to take care of themselves, their homes, their families, and having enjoyment in life far outweighs the problems in most cases.

Technology is enabling.

Can you imagine telling someone with no legs to forsake their wheelchair? How about someone with a pain disorder? Are you going to tell people with crippling mental disorders that they are not allowed to take drugs to normalize and enable them? Are you going to tell deaf people they can’t use Teletype in place of the telephone?

Each of these technological advances were radical in their time; some of them were seen as being destructive, to society or to the individual. It’s hard to imagine any of these people being denied their enabling technologies in today’s first world society (one hopes). I hope to live in a future where my enabling computer habits are accepted.

What harm is being done, to whom, if I take care of myself, my family, my house, my dog, my finances and my business, while still spending many hours a day at my desk at home?